EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/78710
54 EW RESIDENTS May 2012 Cataract tips from the teachers The heavy hand of us until at least several years after residency. Residents near the end of their Sherleen Chen, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary Thomas A. Oetting, M.D. Professor of clinical ophthalmology Director, Ophthalmology Residency Program University of Iowa, Iowa City Chief of Eye Service and deputy director of Surgery Service VAMC Iowa City Roberto Pineda, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary W hile most novice surgeons err on the side of timidity, we occasion- ally see the opposite tendency toward being overly aggressive during surgery. This may manifest physically as mechanical and manual dexterity issues or cognitively due to limited judgment and awareness. Within the delicate confines of the anterior segment, an overly aggressive approach can be quite problematic. Three of our experienced cataract course instructors offer their advice on maintaining control and safety in this situation. Finally, starting with this article, we will be changing to a bi-monthly column. We hope that readers will continue to look for more "Cataract tips from the teachers" every other month. Sherleen Chen, M.D., and Roberto Pineda, M.D. First I must thank EyeWorld maga- zine, Roberto, and Sherleen for bringing visibility to the often secret world of teaching residents. To oper- ate is aggressive and even arrogant in nature. We have to be plenty con- fident in ourselves to forever modify the eyes trusted to us. However, when we are learning a new proce- dure or getting started as residents, an overly aggressive approach is not safe. Progression as we learn should be gradual in small steps building on past success. John Sutphin, M.D., chairman, University of Kansas Med- ical Center, Kansas City, taught me many years ago when I was a new faculty member at Iowa to only change one thing at a time to my routine during a transition. When residents are learning cataract sur- gery there is a tendency to want to quickly move to the latest and great- est technique. I usually remind overly aggressive resident surgeons that they must build on the basics first. The most common over aggres- sive move I encounter is the desire of our residents to bring out that chopper when they are not ready. I try to remind them that before chop comes a good groove; before chop comes slick rotation of the lens with the second instrument; before chop comes centration when a second in- strument is placed. Overly aggressive actions could be a sign of indiffer- ence to the safety of our patients, but most of the time, it is just a sign of passion. The best treatment is to preach patience and give examples of the slow progress of others that residents now respect. Mark F. Pyfer, M.D. Clinical attending surgeon Cataract & Primary Eye Care Service Wills Eye Institute Thomas Jefferson University Philadelphia In my experience, it is unusual to encounter a resident who is overly aggressive in the OR when learning cataract surgery. More commonly, a novice surgeon is somewhat tenta- tive and needs reassurance. However, a few residents I have mentored over the years attempted procedures that were inappropriate or beyond their skill level. Calm but firm guidance and early hands-on attending intervention are required in those cases. We encourage residents to be confident and learn as much as they can under supervision. In fact, the entire training process rewards those who are self-motivated with a drive to succeed. However, patient safety requires that attendings exert good judgment in our supervisory role. One anecdotal (and possibly apoc- ryphal) example is that of a resident, who had never performed an ante- rior vitrectomy during cataract sur- gery, suggesting intentional rupture of the posterior capsule in order to learn the technique. This of course is inexcusable. The dichotomy of resi- dent training is that while we all seek to avoid complications, manag- ing those complications is an impor- tant skill that is best learned under expert guidance. That is the most compelling reason to insist that resi- dents in training perform at least 100-150 proctored cataract surgeries. Malcolm Gladwell, author of The Tipping Point, asserts in his recent book Outliers that 10,000 hours of practice are needed before reaching expert status. For eye surgeons, this translates into about 20,000 proce- dures, a level not attained for most training will occasionally request to perform a maneuver solely for teach- ing purposes, such as placing a three-piece lens in the sulcus. Unless necessitated by a compromised zonule or posterior capsule, I do not permit this on an otherwise routine case. Residents who are fortunate (or skilled) enough to complete 100+ phacoemulsification procedures without vitreous loss should have sufficient experience managing rup- tured globes, traumatic cataracts, or subluxed intraocular lenses to be comfortable with anterior vitrec- tomy. We have been using the EyeSi surgical simulator (VRmagic, Mannheim, Germany) for 3 years, and it has been helpful for begin- ning surgeons. I look forward to ex- panded capability of the simulator when, just as in pilot training, it will be used to simulate rare events such as suprachoroidal hemorrhage. Inappropriately aggressive resi- dent behavior is more commonly seen in the clinic when scheduling patients for surgery. Every year, cer- tain senior residents seem to sign up for more surgery or compete for more challenging cases. We have systems in place monitored by our chief residents to assure fairness in surgical numbers. A cooperative spirit is also fostered by the culture of our program, starting from day one, which helps limit aggressive behavior. Bennie H. Jeng, M.D. Associate professor of ophthalmology University of California, San Francisco (UCSF) Co-director, UCSF Cornea Service Chief, Department of Ophthalmology, San Francisco General Hospital Aggressive doesn't always mean bad. Think about aggressive financial in- vestments that people make—